First Aid Manual: The Authorised Manual of St. John Ambulance, St. Andrew's Ambulance Association and the British Red Cross. 10th Edition (Dk First Aid)

SECONDARY SURVEY | HEAD-TO-TOE EXAMINATION

HEAD-TO-TOE EXAMINATION

Once you have taken the casualty’s history necessary. If possible, examine a casualty who is
(p.46) and asked about any symptoms she responding to you in the position in which you
has (p.47), you should carry out a detailed find her, or one that best suits her condition,
examination. Use all your senses when you unless her life is in immediate danger. If an
examine a casualty: look, listen, feel and smell. unresponsive breathing casualty has been
Always start at the casualty’s head and work placed in the recovery position, leave her in
down; this “head-to-toe” routine is both easily this position while you carry out the head-to-
remembered and thorough. You may have to toe examination.
sensitively loosen, open, cut away or remove
clothing where necessary to examine the Check the casualty’s breathing and pulse
casualty (p.232). Always be sensitive to a rates (pp.52–53), then work from her head
casualty’s privacy and dignity, and ask her downwards (see overleaf). Initially, note any
permission before doing this. minor injuries found but continue your
examination to make sure that you do not miss
Protect yourself and the casualty by putting any concealed potentially serious conditions;
on your disposable gloves. Make sure that you only return to the minor injuries when you have
do not move the casualty more than is strictly completed your examination.

POSSIBLE FINDINGS ON CARRYING OUT AN EXAMINATION

METHOD OF IDENTIFICATION SYMPTOMS OR SIGNS

The casualty may tell you of these ■ Pain ■ Anxiety ■ Heat ■ Cold ■ Loss of sensation ■ Abnormal
symptoms sensation ■ Thirst ■ Nausea ■ Tingling ■ Pain on touch
or pressure ■ Faintness ■ Stiffness ■ Weakness ■ Memory loss
■ Dizziness ■ Sensation of broken bone ■ Sense of
impending doom

You may see these signs ■ Temporary unresponsiveness ■ Anxiety and painful expression ■ Unusual chest
movement ■ Burns ■ Sweating ■ Wounds ■ Bleeding from orifices ■ Response
to touch ■ Response to speech ■ Bruising ■ Abnormal skin colour ■ Muscle
spasm ■ Swelling ■ Deformity ■ Foreign bodies ■ Needle marks ■ Vomit
■ Incontinence ■ Loss of normal movement ■ Containers and other
circumstantial evidence

You may feel these signs ■ Dampness ■ Abnormal body temperature ■ Swelling ■ Deformity
■ Irregularity ■ Grating bone ends

You may hear these signs ■ Noisy or distressed breathing ■ Groaning ■ Sucking sounds from a
You may smell these signs penetrating chest injury ■ Response to touch ■ Response to speech
■ Grating bone (crepitus)
■ Acetone ■ Alcohol ■ Burning ■ Gas or fumes ■ Solvents or glue
■ Urine ■ Faeces ■ Cannabis

» 49

ASSESSING A CASUALTY

« HEAD-TO-TOE EXAMINATION

WHAT TO DO

1 Assess breathing (p.52). Check the rate (fast or 5 Check the nose for discharges as you did
slow), depth (shallow or deep) and nature (is it for the ears. Look for bleeding, clear fluid

easy or difficult, noisy or quiet). Check the pulse or watery blood coming from either nostril.

(p.53). Assess the rate (fast or slow), rhythm Any of these discharges might indicate serious

(regular or irregular) and strength (strong or weak). head injury.

6 Look in the mouth for anything that might
obstruct the airway. If the casualty has

dentures that are intact and fit firmly, leave them.

Look for mouth wounds or burns and check for

irregularity in the line of the teeth.

7 Look at the skin. Note the colour and
temperature: is it pale, flushed or grey-blue

(cyanosis); is it hot or cold, dry or damp? Pale, cold,

sweaty (clammy) skin suggests shock; a flushed,

hot face suggests fever or heatstroke. A blue tinge

Start the physical examination at the indicates lack of oxygen; look for this in the lips,
casualty’s head. Run your hands carefully over
2 ears and face.

the scalp to feel for bleeding, swelling, tenderness

or depression of the bone, which may indicate a

fracture. Be careful not to move the casualty if you

suspect that she may have injured her neck.

8 Loosen clothing around the neck, and
look for signs such as a medical warning

medallion (p.48) or a hole (stoma) in the windpipe.

Run your fingers gently along the spine from the

base of the skull down as far as possible without

moving the casualty; check for irregularity,

3 Speak clearly to the casualty in both ears swelling, tenderness or deformity.
to find out if she responds or if she can hear.

Look for bleeding, clear fluid or watery blood

coming from either ear. These discharges may be

signs of a serious head injury (pp.144–45).

4 Examine both eyes. Note whether they are
open. Check the size of the pupils (the black

area). If the pupils are not the same size it may

indicate head injury. Look for any foreign object,

blood or bruising in the whites of the eyes.

50

HEAD-TO-TOE EXAMINATION

9 Look at the chest. Ask the casualty to breathe 12 If there is any impairment in movement or
deeply, and note whether the chest expands loss of sensation in the limbs, do not move

evenly, easily and equally on both sides. Feel the the casualty to examine the spine, since these

ribcage to check for deformity, irregularity or signs suggest spinal injury. Otherwise, gently

tenderness. Ask the casualty if she is aware of pass your hand under the hollow of the back

grating sensations when breathing, and listen for and check for swelling and tenderness.

unusual sounds. Note whether breathing causes Gently feel the casualty’s abdomen to
detect any evidence of bleeding, and
any pain. Look for any external injuries, such as 13

bleeding or stab wounds. to identify any rigidity or tenderness of the

abdomen’s muscular wall, which could be a sign

of internal bleeding. Compare one side of the

abdomen with the other.

14 Feel both sides of the hips, and examine the
pelvis for signs of fracture. Check clothing

for any evidence of incontinence, which suggests

spinal or bladder injury, or bleeding from orifices,

which suggests pelvic fracture.

15 Check the legs. Look and feel for bleeding,
swelling, deformity or tenderness. Ask the

casualty to raise each leg in turn, and to move

Feel along the collar bones, shoulders, her ankles and knees.
upper arms, elbows, hands and fingers for
10 16 Check the movement and feeling in the
toes. Check that the casualty has no
any swelling, tenderness or deformity. Check
abnormal sensations in her feet or toes.
the movements of the elbows, wrists and fingers
Compare both feet. Look at the skin colour:
by asking the casualty to bend and straighten
grey-blue skin may indicate a circulatory
each joint.
disorder or an injury due to cold.

11 Check that the casualty has no abnormal
sensations in the arms or fingers. If the

fingertips are pale or grey-blue there may be

a problem with blood circulation. Look out for

needle marks on the forearms, or a medical

warning bracelet (p.48).

51

ASSESSING A CASUALTY

MONITORING VITAL SIGNS

When treating a casualty, you may need to and handed over to the medical assistance
assess and monitor his breathing, pulse and taking over (p.21).
level of response. This information can help you
to identify problems and indicate changes in a In addition, if a casualty has a condition that
casualty’s condition. Monitoring should be affects his body temperature, such as fever, heat
repeated regularly, and your findings recorded stroke or hypothermia, you will also need to
monitor his temperature.

LEVEL OF RESPONSE ■■A – Is the casualty Alert? Are her eyes open
and does she respond to questions?
You need to assess and monitor a casualty’s
level of response and make a note of any change ■■V – Does the casualty respond to Voice? Can
in her condition (deterioration or improvement) she open her eyes, answer simple questions
while she is in your care. Any injury or illness and obey commands?
that affects the brain may alter a person's ability
to respond, and any deterioration is potentially ■■P – Does the casualty respond to Pain?
serious. Assess the level of response using the Does she open her eyes or move if you pinch
AVPU scale (right) and repeat the assesment at her ear lobe?
regular intervals.
■■U – Is the casualty Unresponsive to any
stimulus (unconscious)?

BREATHING Checking a casualty’s breathing rate
Observe the chest movements and count the number
When assessing a casualty’s breathing, of breaths per minute. Use a watch to time breaths.
check the rate of breathing and listen for For a baby or young child, place your hand on the
any breathing difficulties or unusual noises. chest and feel for movement.

An adult’s normal breathing rate is 12–16
breaths per minute; in babies and young
children, it is 20–30 breaths per minute. When
checking breathing, listen for breaths and watch
the casualty’s chest movements. For a baby or
young child, it might be easier to place your
hand on the chest and feel for movement of
breathing. Record the following information:
■■Rate – count the number of breaths per

minute
■■Depth – are the breaths deep or shallow
■■Ease – are the breaths easy, difficult

or painful
■■Noise – is the breathing quiet or noisy, and

if noisy, what are the types of noise

52

MONITORING VITAL SIGNS

PULSE The pulse may be felt at the wrist (radial pulse),
or if this is not possible, the neck (carotid pulse).
Each heartbeat creates a wave of pressure In babies, the pulse in the upper arm (brachial
as blood is pumped along the arteries pulse) is easier to find.
(pp.108–109). Where arteries lie close to the
skin surface, such as on the inside of the wrist When checking a pulse, use your fingers (not
and at the neck, this pressure wave can be felt your thumb) and press lightly against the skin.
as a pulse. The normal pulse rate for an adult is Record the following points.
60–80 beats per minute. The pulse rate is faster ■■Rate (number of beats per minute).
in children and may be slower in very fit adults. ■■Strength (strong or weak).
An abnormally fast or slow pulse rate may be a ■■Rhythm (regular or irregular).
sign of illness or injury.

Brachial pulse Radial pulse Carotid pulse
Place the pads of two fingers Place the pads of three fingers just Place the pads of two fingers in the
on the inner side of an infant’s below the wrist creases at the base hollow between the large neck
upper arm. of the thumb. muscle and the windpipe.

BODY TEMPERATURE the result of heat exhaustion or heatstroke
(pp.184–85). A lower body temperature may
Although not a vital sign, you may need to result from exposure to cold and/or wet
record temperature to assess body temperature. conditions – hypothermia (pp.186–88) – or it
You can feel exposed skin on the forehead for may be a sign of life-threatening infection or
example, but use a thermometer to obtain an shock (pp.112–13). There are different several
accurate reading. Normal body temperature is types of thermometer, see below.
37°C (98.6°F). A temperature above this (fever)
is usually caused by infection, but can also be

Digital thermometer Forehead thermometer Ear sensor
Used to measure temperature A heat-sensitive strip for use on a Place the probe inside the ear.
under the tongue or armpit. Leave young child. Hold it against the Press the measurement key and
it in place until it makes a beeping child’s forehead for about 30 wait for a beeping sound, then read
sound (about 30 seconds), then seconds. The colour on the strip the display. This thermometer can
read the display. indicates temperature. be used while a person is asleep.

53

To stay alive we need an adequate supply
of oxygen to enter the lungs and be
transferred to all cells in the body by the
circulating blood. If a person is deprived
of oxygen for any length of time, the brain
will begin to fail. As a result, the casualty
will eventually become unresponsive,
breathing will cease, the heart will stop
and death results.

The casualty’s airway must be kept
open so that breathing can occur, allowing
oxygen to enter the lungs and be circulated
in the body.

Therefore, the priority of a first aider
when treating any collapsed casualty is
to establish an open airway and maintain
breathing and circulation. An AED
(automated external defibrillator) may
be used to “shock” a fibrillating heart back
into a normal rhythm. This chapter outlines
the priorities to remember when dealing
with an unresponsive adult, child or infant.

There are important differences in
the treatment for unresponsive infants,
children and adults; this chapter gives
separate step-by-step instructions for
dealing with each of these groups.

AIMS AND OBJECTIVES

■■ To maintain an open airway, to check breathing and
resuscitate if required

■■ To call 999/112 for emergency help

THE UNRESPONSIVE
CASUALTY

THE UNRESPONSIVE CASUALTY

BREATHING AND CIRCULATION

Oxygen is essential to support life. Without it, carbon dioxide, is released and exhaled in the
cells in the body die – those in the brain survive breath. When oxygen has been transferred to
only a few minutes without oxygen. Oxygen is the blood cells it is carried from the lungs to the
taken in when we breathe in (pp.90–91), and it heart through the pulmonary veins. The heart
is then circulated to all the body tissues via the then pumps the oxygenated blood to the rest
circulatory system (p.108). It is vital to maintain of the body via blood vessels called arteries.
breathing and circulation in order to sustain life.
After oxygen is given up to the body tissues,
The process of breathing enables air, which deoxygenated blood is brought back to the
contains oxygen, to be taken into the air sacs heart by blood vessels called veins (p.108).
(alveoli) in the lungs. Here, the oxygen is The heart pumps this blood to the lungs via the
transferred across blood vessel walls into the pulmonary arteries, where the carbon dioxide is
blood, where it combines with blood cells. At released and the blood is reoxygenated before
the same time, the waste product of breathing, circulating around the body again.

Lungs Fresh oxygen is drawn into the lungs via the
nose and mouth by the windpipe (trachea)

Deoxygenated Oxygenated blood
blood is pumped returns from the lungs
to the lungs by the to the heart
heart through
the pulmonary Oxygenated blood
arteries leaves the heart to
be circulated around
Deoxygenated the body via the aorta
blood returns
from body Heart pumps
tissue to oxygenated blood
the heart around the body

Red blood cell

Direction of
oxygen flow

How the heart and lungs Air sac Direction of
work together (alveolus) carbon dioxide
Air containing oxygen is taken into the flow
lungs via the mouth and nose. Blood
is pumped from the heart to the lungs, Exchange of gases in the air sacs
where it absorbs oxygen. Oxygenated Carbon dioxide passes out of blood
blood is returned to the heart before cells into air sacs (alveoli). Oxygen
being pumped around the body. crosses the walls of alveoli into
blood cells.

56 SEE ALSO How breathing works p.91 | The heart and blood vessels pp.108–109 | The respiratory system p.90

BREATHING AND CIRCULATION | LIFE-SAVING PRIORITIES

LIFE-SAVING PRIORITIES

The procedures set out in this chapter can likely reason for the heart to stop. Because
maintain a casualty’s circulation and breathing. of this they should therefore be given FIVE
initial rescue breaths before the chest
With an unresponsive casualty your priorities compressions are started.
are to maintain an open airway, to maintain
blood circulation (to get oxygenated blood to CHEST-COMPRESSION-ONLY CPR
the tissues), and to breathe for the casualty (to
get oxygen into the body). In an adult during If you have not had any training in CPR, or you
the first minutes after the heart stops (cardiac are unwilling or unable to give rescue breaths, you
arrest), the blood oxygen level remains can give chest compressions only. The emergency
constant, so chest compressions are more services will give instructions for chest-
important than rescue breaths in the initial compression-only CPR (pp.70–71).
phase of resuscitation. After about two to four
minutes, the blood oxygen level falls and rescue KEY ELEMENTS FOR SURVIVAL
breathing becomes more important. The
combination of chest compressions and rescue If all of the following elements are complete,
breaths is known as cardiopulmonary the casualty’s chances of survival are as good
resuscitation, or CPR. as they can possibly be:
■■Emergency help is called quickly
In addition to CPR, a machine called an AED ■■CPR is used to provide circulation and oxygen
(automated external defibrillator) can be used
to deliver an electric shock that may restore a to the body tissues
normal heartbeat (pp.84–87). In children and ■■AED is used promptly
infants, a problem with breathing is the most ■■Specialised treatment and advanced care

CHAIN OF SURVIVAL arrive quickly

EARLY HELP EARLY CPR EARLY EARLY ADVANCED
Call 999/112 for Chest compressions DEFIBRILLATION CARE
emergency help so and rescue breaths A controlled electric Specialised treatment
that an AED and are used to “buy shock from an AED by paramedics and in
expert help can be time” until expert is given. This can hospital stabilises the
brought to the help arrives. “shock” the heart into casualty’s condition.
casualty. a normal rhythm.

» 57

THE UNRESPONSIVE CASUALTY

« LIFE-SAVING PRIORITIES

IMPORTANCE OF MAINTAINING CIRCULATION

If the heart stops beating, blood does not To ensure that the blood is supplied with
circulate through the body. As a result, vital enough oxygen, chest compressions should be
organs – most importantly the brain – become combined with rescue breathing (opposite).
starved of oxygen. Brain cells are unable to
survive for more than three to four minutes GIVING CHEST COMPRESSIONS
without a supply of oxygen.

Some circulation can be maintained
artificially with chest compressions (pp.66–67).
These act as a mechanical aid to the heart in
order to get blood flowing around the body.
Pushing vertically down on the centre of the
chest increases the pressure in the chest cavity,
expelling blood from the heart and forcing it
into the tissues. As pressure on the chest is
released, the chest recoils, or comes back up,
and more blood is “sucked” into the heart; this
blood is then forced out of the heart by the next
compression. It is possible to find the hand
position for chest compressions without
removing clothing.

RESTORING HEART RHYTHM

A machine called an AED (automated external
defibrillator) will be used to attempt to restart
the heart when it has stopped (pp.84–87). The
earlier the AED is used, the greater the chance
of the casualty surviving. With each minute’s
delay, the chances of survival fall – however, do
not leave a casualty to search for an AED; ask
a bystander to fetch one (p.60). AEDs can be
used safely and effectively without any prior
training in their use.

AEDs are found in many public places, such
as railway stations, shopping centres, airports,
coach stations and ferry ports. They are
generally housed in cabinets, often marked with
a recognised symbol (p.85), and placed where
they can be easily accessed – on station
platforms for example. The cabinets are not
locked, but most are fitted with an alarm that is
activated when the door is opened.

USING AN AED

58

LIFE-SAVING PRIORITIES

AN OPEN AIRWAY difficult and noisy and may stop altogether.
Lifting the casualty's chin and tilting the
An unresponsive casualty’s airway can become head back lifts the tongue away from the
narrowed or blocked. This can be the result of entrance of the air passage, which allows
muscular control being lost, which allows the the casualty to breathe.
tongue to fall back and block the airway. When
this happens, the casualty’s breathing becomes

Tongue Air cannot Blocked airway Tongue free Air entering Open airway
blocking enter airway In an unresponsive of airway airway In the head-tilt,
airway casualty, the chin-lift position,
muscle control in the tongue is
the tongue is lost lifted from the
so it falls back, back of the
blocking the throat and the
throat and airway. trachea is open,
so the airway will
be clear.

BREATHING FOR A CASUALTY CAUTION
AGONAL BREATHING
Exhaled air contains about 16 per cent oxygen This type of breathing usually takes the form
(only 5 per cent less than inhaled air) and a of short, irregular gasps for breath. It is common
small amount of carbon dioxide. Your exhaled in the first few minutes after a cardiac arrest. It
breath therefore contains enough oxygen to should not be mistaken for normal breathing and,
supply another person with oxygen – and if it is present, chest compressions and rescue
potentially keep him alive – when it is forced breaths (cardiopulmonary resuscitation/CPR)
into his lungs during rescue breathing. should be started without hesitation.

By giving a casualty rescue breaths (p.67),
you force air into his air passages. This reaches
the air sacs (alveoli) in the lungs, and oxygen
is then transferred to the blood vessels in
the lungs.

When you take your mouth away from the
casualty’s, his chest falls, and air containing
waste products is pushed out, or exhaled, from
his lungs. This process, performed together with
chest compressions (pp.66–67), can supply the
tissues with oxygen until help arrives.

GIVING RESCUE BREATHS » 59

THE UNRESPONSIVE CASUALTY

« LIFE-SAVING PRIORITIES

ADULT RESUSCITATION following pages. Carry out the following
steps in rapid succession to minimise
This action plan is a summary of the techniques interruption to CPR.
to use when attending a collapsed adult. There
are more detailed instructions given on the

CHECK CASUALTY’S RESPONSE Leave the casualty in the position
found. Use the primary survey
■■ Try to get a response by asking (pp.44–45) to identify the most
questions and gently shaking his YES serious injury and treat in order
shoulders (p.62).
of priority.
Is there a response?

NO If possible, leave the casualty in
the position found. Use the
OPEN THE AIRWAY; CHECK FOR BREATHING primary survey (pp.44–45) to
identify the most serious injury
■■ Tilt the head back and lift the chin YES and treat in order of priority. Place
to open the airway (p.63).
the casualty in the recovery
■■ Check for breathing (p.63). position (pp.64–65). Call 999/112
Is he breathing normally? for emergency help.

NO

Ask a helper to call 999/112 for emergency help and fetch an AED
■■ If you are on your own, make the call yourself.

BEGIN CPR ■■ If you are on your own, start CPR
straight away; do not leave the
■■ Give 30 chest compressions casualty in search of an AED.
(pp.66–67).
■■ If you have not had training in
■■ Give TWO rescue breaths (p.67). CPR, or you are unwilling or unable
■■ Alternate 30 chest compressions to give rescue breaths, you can
give chest compressions only
with TWO rescue breaths (30:2) (pp.70–71). The emergency
until help arrives; the casualty services will give instructions for
shows signs of becoming chest-compression-only CPR.
responsive, for example, coughing,
opening his eyes, speaking, or ■■ If the casualty starts breathing
moving purposefully, and starts normally, but remains
to breathe normally; or you are unresponsive, place him in the
too exhausted to continue. recovery position (pp.64–65).

60

LIFE-SAVING PRIORITIES

CHILD/INFANT RESUSCITATION

This action plan shows the order for the between the ages of one and puberty or an
techniques to use when attending a child infant under one year.

CHECK CHILD’S RESPONSE Leave the child in the position
found. Use the primary survey
■■ Try to get a response by asking YES (pp.44–45) to identify the most
questions and gently tapping serious injury and treat in order
the child’s shoulder or an of priority.
infant’s foot.

Is there a response?

NO

OPEN THE AIRWAY; CHECK FOR BREATHING If possible, leave the casualty in
the position found. Use the
■■ Tilt the head back and lift the chin primary survey (pp.44–45) to
to open the airway (child, p.73; YES identify the most serious injury
infant, p.80).
and treat in order of priority. Place
■■ Check for breathing (child, p.73; the child in the recovery position
infant, p.81). (pp.74–75), or hold an infant (p.81).
Call 999/112 for emergency help.
Is she breathing normally?

NO

Ask a helper to call 999/112 for emergency help and, for a child,
fetch an AED, ideally with paediatric pads.
■■ Do not use an AED on an infant.

GIVE INITIAL RESCUE BREATHS ■■ It is better to give a combination
of rescue breaths and chest
■■ Carefully remove any visible compressions with infants and
obstruction from the mouth. children. However, if you have not
had training in CPR, or you are
■■ Give FIVE initial rescue breaths unwilling or unable to give rescue
(child, p.76; infant, p.80). breaths, you may give chest
compressions only (pp.70–71).
BEGIN CPR The emergency services will
give instructions for chest-
■■ Give 30 chest compressions compression-only CPR.
(child, p.77; infant, p.83).
■■ If you are alone, carry out CPR
■■ Follow with TWO rescue breaths. for one minute before calling for
■■ Alternate 30 chest compressions emergency help. Take the infant
or child with you to the phone
with TWO rescue breaths (30:2) if necessary – never leave a child
until emergency help arrives; the to search for an AED.
child shows signs of becoming
responsive, such as coughing, ■■ If the child starts breathing
opening her eyes, speaking, or normally, but remains
moving purposefully, and starts to unresponsive, place her in the
breathe normally; or you are too recovery position (child, pp.74–75;
exhausted to continue. infant, p.81).

61

THE UNRESPONSIVE CASUALTY

UNRESPONSIVE ADULT

The following pages describe techniques for for example, is the casualty breathing? The
the management of an unresponsive adult who steps given here tell you what to do next;
may require resuscitation. work through them in rapid succession with
minimal interruption.
Always approach and treat the casualty from
the side, kneeling down next to his head or The first priority is to open the casualty’s
chest. You will then be in the correct position to airway so that he can breathe or you can give
perform all the stages of resuscitation: opening rescue breaths. If normal breathing returns at
the airway; checking breathing; and giving chest any stage, you should place the casualty in the
compressions and rescue breaths (together recovery position. If the casualty is not breathing,
called cardiopulmonary resuscitation, or CPR). the early use of an AED (automated external
At each stage you will have decisions to make – defibrillator) may increase his chance of survival.

CAUTION HOW TO CHECK THE RESPONSE
■■ Always assume that there is a
On discovering a collapsed casualty, you should first make sure
neck injury and shake the the scene is safe and then establish whether he is responsive or
shoulders very gently. unresponsive. Do this by gently shaking the casualty’s shoulders.
Ask “What has happened?” or give a command such as, “Open
your eyes”. Always speak loudly and clearly to the casualty.

IF THERE IS A RESPONSE

1 If there is no further danger, leave the casualty
in the position in which he was found. Use the

primary survey (pp.44–45) to identify the most

serious injury and treat conditions in order of

priority. Summon help if needed.

2 Monitor and record vital signs – breathing,
pulse and level of response (pp.52–53) – until

help arrives or the casualty recovers.

IF THERE IS NO RESPONSE

1 Shout for help. Leave the casualty in the
position in which he was found and open

the airway.

2 If you are unable to open the airway in
the position in which he was found, roll

him on to his back and open the airway. Go to

How to open the airway (opposite).

62

UNRESPONSIVE ADULT

HOW TO OPEN THE AIRWAY

1 Place one hand on his forehead. Gently tilt his 2 Place the fingertips of your other hand on the
head back. As you do this, the mouth will fall point of the casualty’s chin and lift the chin.

open slightly. Check the casualty’s breathing. Go to How to check

breathing, below.

HOW TO CHECK BREATHING 10 seconds before deciding whether or not the
casualty is breathing normally. Breathing may
Keeping the airway open, look, listen and feel be agonal (p.59). If there is any doubt, act as if
for normal breathing: look for chest movement; it is not normal.
listen for sounds of breathing; and feel for
breaths on your cheek. Do this for no more than

IF THE CASUALTY IS BREATHING

1 Use the primary survey (pp.44–45) to identify
the most serious injury and treat conditions in

order of priority.

2 Place the casualty in the recovery
position (pp.64–65) and call 999/112 for

emergency help.

3 Monitor and record vital signs – breathing,
pulse and level of response (pp.52–53) – while

waiting for help to arrive. Go to How to place

casualty in recovery position (pp.64–65).

IF THE CASUALTY IS NOT BREATHING

1 Ask a helper to call 999/112 for emergency
help. Ask the person to bring an AED if one

is available. If you are alone, make the call

yourself, ideally use your mobile device set to

speaker phone to make the call.

2 Begin CPR with chest compressions – do not
leave a casualty in search of an AED. Go to

How to give CPR (pp.66–67). » 63

« UNRESPONSIVE ADULTTHE UNRESPONSIVE CASUALTY

HOW TO PLACE CASUALTY IN RECOVERY POSITION

If the casualty is found lying on his side or recovery position. If the mechanism of injury
front, rather than his back, not all the following suggests a spinal injury, treat as described
steps will be necessary to place him in the opposite and on pp.157–59.

WHAT TO DO

1 Kneel beside the casualty. Remove his 3 Bring the arm that is farthest from you
spectacles and any bulky objects, such as across the casualty’s chest, and hold the

mobile phones or large bunches of keys, from his back of his hand against the cheek nearest to

pockets. Do not search his pockets for small items. you. With your other hand, grasp the far leg just

Make sure that both of the casualty’s legs are above the knee and pull it up, keeping the foot
straight. Place the arm that is nearest to you at
2 flat on the ground.

right angles to the casualty’s body, with the elbow

bent and the palm facing upwards.

4 Keeping the casualty’s hand pressed against
his cheek, pull on the far leg and roll the

casualty towards you and on to his side.

64

UNRESPONSIVE ADULT

5 Adjust the upper leg so that both the hip and 7 If necessary, adjust the hand under the cheek
the knee are bent at right angles. to keep the airway open.

6 Tilt the casualty’s head back and tilt his chin so
that the airway remains open (p.63).

8 If it has not already been done, call 999/112
for emergency help. Monitor and record vital

signs – breathing, pulse and level of response

(pp.52–53) – while waiting for help to arrive.

9 If the casualty is likely to remain in the
recovery position for a while, after 30 minutes

roll him on to his back, and then roll him on to the

opposite side – unless other injuries prevent you

from doing this.

SPECIAL CASE RECOVERY POSITION FOR SUSPECTED SPINAL INJURY

If you suspect a spinal injury (pp.157–59) and
need to place the casualty in the recovery
position because you cannot maintain an
open airway, try to keep the spine straight
using the following guidelines:
■■ If you are alone, use the technique shown

opposite and above.
■■ If you have one helper, one of you should

steady the head while the other turns the
casualty (right).
■■ With three people, one person should steady
the head while another turns the casualty. The
third person should keep the casualty’s back
straight during the manoeuvre.
■■ If there are four or more people in total, use the
log-roll technique (p.159).

» 65

« UNRESPONSIVE ADULTTHE UNRESPONSIVE CASUALTY

HOW TO GIVE CPR

WHAT TO DO

1 Kneel beside the casualty level with his chest. HAND POSITION
Place the heel of one hand on the centre of the Place your hand on the casualty’s breastbone as
indicated here. Make sure that you do not press
casualty’s chest. You can identify the correct hand on the casualty’s ribs, the lower tip of the breastbone
or the upper abdomen.
position for chest compressions through a

casualty’s clothing.

Hand position Breastbone

Ribs Lower tip of
Upper breastbone
abdomen

2 Place the heel of your other hand on top of the 3 Leaning over the casualty, with your arms
first hand, and interlock your fingers, making straight, press down vertically on the

sure the fingers are kept off the ribs. breastbone and depress the chest by 5–6cm

(2–2½in). Release the pressure without removing

your hands from his chest. Allow the chest to

come back up fully (recoil) before giving the

next compression.

66

UNRESPONSIVE ADULT

4 Compress the chest 30 5 Move to the casualty’s CAUTION
times at a rate of 100–120 head and make sure that If there is more than one rescuer,
change over every 1–2 minutes,
compressions per minute. the airway is still open. Put one with minimal interruption to
chest compressions.
The time taken for compression hand on his forehead and two

and release should be about fingers of the other hand under

the same. the tip of his chin. Move the

hand that was on the forehead

down to pinch the soft part of

the nose with the finger and

thumb. Allow the casualty’s

mouth to fall open

6 Take a breath and place 7 Maintaining head tilt 8 Continue the cycle of 30
your lips around the and chin lift, take your chest compressions followed

casualty’s mouth, making mouth off the casualty’s mouth by TWO rescue breaths (30:2)

sure you have a good seal. Blow and look to see the chest fall. until: emergency help arrives

into the casualty’s mouth until If the chest rises visibly as and takes over; the casualty

the chest rises. A complete you blow and falls fully when shows signs of becoming

rescue breath should take one you lift your mouth away, you responsive – such as coughing,

second. If the chest does not have given a rescue breath – opening his eyes, speaking, or

rise, you may need to adjust one rescue breath should take moving purposefully – and starts

the head position (How to open one second. Give a second to breathe normally; or you are

the airway, p.63). rescue breath. too exhausted to continue.

» 67

« UNRESPONSIVE ADULTTHE UNRESPONSIVE CASUALTY

SPECIAL CONSIDERATIONS FOR CPR

There are circumstances when it may be more from his mouth, then immediately roll him

difficult to deliver CPR: onto his back again and recommence CPR.

■■If you have not been trained in CPR or are ■■If a woman in the late stage of pregnancy

unwilling or unable to give rescue breaths you requires CPR, raise her right hip off the

can give chest compressions only (pp.70–71). ground by tilting it upwards before you begin

An ambulance dispatcher will give compressions, see below.
instructions for chest-compression-only CPR. ■■Modified rescue breathing may be necessary
■■If there is more than one rescuer, change over
every 1–2 minutes, with minimal interruption in some cases: for example, if a casualty has
a chemical around the mouth, you can give

to chest compressions. rescue breaths through the nose (opposite).

■■If the casualty vomits during CPR, roll him A casualty may breathe through a hole in the

away from you onto his side, ensuring that his front of the neck – a stoma – opposite). You

head is turned towards the floor to allow can also use a pocket mask or face shield

vomit to drain away. Clear any residual debris when giving rescue breaths.

CPR IN LATE STAGES OF PREGNANCY
If a heavily pregnant woman is lying on her returning to the heart, which reduces

back, the pregnant uterus will press against the the amount of blood circulation that can be

large blood vessels in the abdomen. This achieved with chest compressions. To prevent

restricts blood from the lower part of the body this from happening, tilt her right hip upwards.

Positioning the woman
Keep the woman's upper body
as flat on the floor as possible in
order to give good-quality
compressions. Raise her right hip
and ask a helper to kneel beside
the woman so that his knees are
underneath the raised hip. If you
are on your own, place tightly
rolled up clothing or towels under
the woman’s hip to lift it.

PROBLEMS WITH RESCUE BREATHING

If a casualty's chest does not rise when giving any obvious obstructions, but do not do a
rescue breaths: finger sweep of the mouth.
■■Re-check the head tilt and chin lift. Make no more than two attempts to achieve
■■Re-check the casualty's mouth and remove rescue breaths before repeating compressions.

68

UNRESPONSIVE ADULT

VARIATIONS FOR RESCUE BREATHING

There are some situations where mouth-to- FACE SHIELDS AND POCKET MASKS
mouth rescue breaths are not appropriate and Face shields are plastic barriers with a filter that
you need to use a mouth-to-nose or mouth-to- is placed over the casualty’s mouth. A pocket
stoma technique. mask has a mouthpiece through which breaths
are given. If you have one of these barrier
devices, avoid unnecessary interruptions to
CPR when you use it.

Mouth-to-nose rescue breathing Using a face shield
If a casualty has injuries to the mouth that make it Tilt the casualty’s head back to open the airway. Place
impossible to achieve a good seal, you can use the the shield over the casualty’s face so that the filter is
mouth-to-nose method for giving rescue breaths. over the mouth and pinch the nostrils shut. Deliver
With the casualty’s mouth closed, form a tight seal rescue breaths through the filter.
with your lips around the nose and blow steadily
into the casualty’s nose. Then allow the mouth
to fall open to let the air escape.

Mouth-to-stoma rescue breathing Using a pocket mask
A casualty who has had his voice-box surgically Kneel behind the casualty’s head. Open the airway
removed breathes through an opening in the front and place the mask, narrow end towards you, over
of the neck (a stoma), rather than through the mouth the casualty’s mouth and nose. Deliver rescue breaths
and nose. Always check for a stoma before giving through the mouthpiece.
rescue breaths. If you find a stoma, close off the
mouth and nose with one hand and then breathe
into the stoma.

WHEN THE AMBULANCE ARRIVES

The ambulance service may initially send a you are asked to help you should listen carefully
sole responder in a fast-response vehicle or
a community first responder ahead of the and follow the instructions given (p.23).
ambulance. If an AED is not already attached
to the casualty, the ambulance personnel will The ambulance personnel will make a decision
do that. They will also use additional drugs and
equipment to provide advanced care (p.57). If whether to transfer the casualty to hospital

immediately or to continue treatment at the

scene. Any decision to stop resuscitation can only

»be made by a health care professional. 69

« UNRESPONSIVE ADULTTHE UNRESPONSIVE CASUALTY

CAUTION CHEST-COMPRESSION-ONLY CPR

■■ If there is more than one rescuer Healthcare professionals and trained first aiders will deliver
swap every 1–2 minutes to CPR using chest compressions combined with rescue breaths
prevent fatigue. Make sure there (pp.66–67). However, if you have not had training in CPR or you
is minimal interruption when are unwilling or unable to give rescue breaths, chest-
you change over to maintain the compression-only CPR has been shown to be of great benefit
quality of the compressions. certainly in the first minutes after the heart has stopped. The
emergency services will give instructions for chest-compression-
■■ For unresponsive children and only resuscitation for an unresponsive casualty when advising an
infants who are not breathing, untrained person by telephone. Put your device on speaker-
it is best to give CPR using phone mode so that you can deliver first aid and talk to the
rescue breaths with chest dispatcher. Start chest compressions as soon as possible and
compressions (pp.76–77 and continue them until: emergency help arrives and takes over; the
pp.82–83). casualty shows signs of becoming responsive – such as coughing,
opening his eyes, speaking or moving purposefully – and starts
■■ If a casualty has been rescued breathing normally; or you are too exhausted to continue.
from water and is not breathing,
it is best to give CPR using
rescue breaths and chest
compressions (Drowning, p.100).

WHAT TO DO

1 Check for a response.
Gently shake the casualty’s

shoulders, and talk to him or give

a command (p.62).

IF THERE IS A RESPONSE
Use the primary survey (pp.44–45)
to identify the most serious injury
and treat conditions in order
of priority.

IF THERE IS NO RESPONSE
Shout for help and open the
airway, step 2.

2 Open the casualty’s airway.
Place one hand on the

forehead and gently tilt the head

– the mouth should fall open.

Place the fingertips of your other

hand on the chin and lift it.

70

UNRESPONSIVE ADULT

3 Check breathing: look,
listen and feel for signs

of breathing for no more

than 10 seconds.

IF HE IS BREATHING
Use the primary survey (pp.44–45)
to identify the most serious injury
and treat conditions in order of
priority. Place in the recovery
position (pp.66–65).

IF HE IS NOT BREATHING
Call 999/112 for emergency help
then begin chest compressions,
step 4.

4 Kneel beside the casualty,
level with his chest. Place

one hand on the centre of the

chest (p.66) – you can identify the

position through clothing. Put the

heel of your other hand on top of

the first and interlock your fingers.

Make sure your fingers are not in

contact with the ribs.

5 Begin chest compressions:
lean over the casualty, with

your arms straight and press down

vertically on his breastbone,

depressing the chest by about

5–6cm (2–2½in). Release the

pressure – but do not take your

hands off the chest – and let the

chest come back up. The time

taken for compression and release

should be about the same.

6 Continue with chest
compressions at a rate of

100–120 per minute until:

emergency help arrives; the

casualty shows signs of becoming

responsive – such as coughing,

opening his eyes, speaking or

moving purposefully – and starts

breathing normally; or you are

too exhausted to continue.

71

THE UNRESPONSIVE CASUALTY

UNRESPONSIVE CHILD ONE YEAR TO PUBERTY

The following pages describe the techniques example, is the child breathing? The steps given
that may be needed for the resuscitation of here tell you what to do next; work through all
an unresponsive child aged between one year of them in rapid succession with minimal
and puberty. interruption. Your first priority is to open the
child’s airway, so that she can breathe, or so
When treating a child, always approach and that you can give rescue breaths. If normal
treat her from the same side, kneeling down breathing resumes, place the child in the
next to the head or chest. You will then be in recovery position (pp.74–75).
the correct position to carry out all the different
stages of resuscitation: opening the airway, If a child with a known heart condition
checking breathing and giving rescue breaths collapses, call 999/112 for emergency help
and chest compressions (together known as immediately and ask for an AED to be brought
cardiopulmonary resuscitation, or CPR). At each (pp.84–87). Early access to advanced care can
stage you will have decisions to make; for be life-saving.

HOW TO CHECK RESPONSE or give a command such as, “Open your eyes”.
Place one hand on her shoulder, and gently tap
On discovering a collapsed child, you should her to see if there is a response.
first establish whether she is responsive or
unresponsive. Do this by speaking loudly and
clearly to the child. Ask “What has happened?”

IF THERE IS A RESPONSE

1 If there is no further danger, leave the
child in the position in which she was found.

Use the primary survey (pp.44–45) to identify the

most serious injury and treat conditions in order

of priority.

2 Monitor and record vital signs – breathing,
pulse and level of response (pp.52–53) – until

emergency help arrives or the child recovers.

IF THERE IS NO RESPONSE

1 Shout for help. Leave the child in the position
in which she was found, and open the airway.

2 If you are unable to open the airway in
the position in which she was found, roll the

child on to her back and open the airway. Go to

How to open the airway (opposite).

72

UNRESPONSIVE CHILD

HOW TO OPEN THE AIRWAY

1 Place one hand on the child’s forehead. Gently 2 Place the fingertips of your other hand on the
tilt her head back. As you do this, the mouth point of the chin and lift. Do not push on the

will fall open slightly. soft tissues under the chin since this may block the

airway. Now check to see if the child is breathing.

Go to How to check breathing (below).

HOW TO CHECK BREATHING breathing and feel for breaths on your cheek.
Do this for no more than 10 seconds.
Keep the airway open and look, listen and
feel for normal breathing – look for chest
movement, listen for sounds of normal

IF THE CASUALTY IS BREATHING

1 Use the primary survey (pp.44–45) to identify
the most serious injury and treat conditions in

order of priority.

2 Place the child in the recovery position and
call 999/112 for emergency help.

3 Monitor and record vital signs – breathing,
pulse and level of response (pp.52–53) – while

waiting for help to arrive. Go to How to place child

in recovery position (pp.74–75).

IF THE CASUALTY IS NOT BREATHING

1 Ask a helper to call 999/112 for emergency
help. If you are on your own, perform CPR

for one minute and then make the emergency

call yourself. Use your mobile device set to speaker

phone to make the call or take the child with you to

the telephone if necessary.

2 Begin CPR with FIVE initial rescue breaths.
Go to How to give CPR (pp.76–77).

» 73

THE UNRESPONSIVE CASUALTY

«UNRESPONSIVE CHILD ONEYEARTOPUBERTY

HOW TO PLACE CHILD IN RECOVERY POSITION

If the child is found lying on her side or front, position. If the mechanisms of injury suggest a
rather than her back, not all of these steps will spinal injury, treat as described on pp.157–59.
be necessary to place her in the recovery

WHAT TO DO

1 Kneel beside the child. Remove her spectacles 3 Bring the arm that is farthest from you across
and any bulky objects from her pockets, but do the child’s chest, and hold the back of her hand

not search them for small items. against the cheek nearest to you. With your other

Make sure that both of the child’s legs are hand, grasp the far leg just above the knee and pull
straight. Place the arm nearest to you at right
2 it up, keeping the foot flat on the ground.

angles to the child’s body, with the elbow bent and

the palm facing upwards.

4 Keeping the child’s hand pressed against her
cheek, pull on the far leg and roll the child

towards you and on to her side.

74

UNRESPONSIVE CHILD

5 Adjust the upper leg so that both the hip and SPECIAL CASE RECOVERY POSITION
the knee are bent at right angles. Tilt the child’s FOR SUSPECTED SPINAL INJURY

head back and lift the chin so that the airway If you suspect a spinal injury (pp.157–59) and need
to place the child in the recovery position because
remains open. you cannot maintain an open airway, try to keep
the spine straight using the following guidelines:
■■ If you are on your own, use the technique shown

opposite and left.
■■ If there are two of you, one person should steady the

head while the other turns the child, see below.
■■ If there are three of you, one person should steady the

head while one person turns the child. The third
person should keep the child’s back straight during the
manoeuvre.
■■ If there are four or more people in total, use the log-
roll technique (p.159).

6 If necessary, adjust the hand under the cheek
to make sure that the head remains tilted and

the airway stays open. If it has not already been

done, call 999/112 for emergency help. Monitor

and record vital signs – breathing, pulse and level

of response (pp.52–53) – until help arrives.

7 If the child is likely to remain in the recovery
position for a while, after 30 minutes you

should roll her on to her back, then turn her on to

the opposite side – unless other injuries prevent

you from doing this.

» 75

THE UNRESPONSIVE CASUALTY

«UNRESPONSIVE CHILD ONEYEARTOPUBERTY

HOW TO GIVE CPR

WHAT TO DO

1 Ensure the airway is still open by keeping one 2 Pick out any visible obstructions from the
hand on the child’s forehead and two fingers of mouth. Do not sweep the mouth with your

the other hand on the point of her chin. finger to look for obstructions.

3 Pinch the soft part of the 4 Take a deep breath in 5 Maintaining head tilt and
child’s nose with the finger before placing your lips chin lift, take your mouth

and thumb of the hand that was around the child’s mouth, off the child’s mouth and look to

on the forehead. Make sure that making sure that you form an see the chest fall. If the chest

her nostrils are closed to prevent airtight seal. Blow steadily into rises visibly as you blow and falls

air from escaping. Allow her the child’s mouth; the chest fully when you lift your mouth,

mouth to fall open. should rise. you have given a rescue breath.

Each complete rescue breath

should take one second. If the

chest does not rise you may

need to adjust the head (p.73).

Give a child FIVE initial

rescue breaths.

76

6 Kneel level with the child’s chest. Place one UNRESPONSIVE CHILD
hand on the centre of her chest. This is the
CAUTION
point at which you will apply pressure. With more than one rescuer, change every 1–2
minutes with minimal interruption to compressions.

HAND POSITION
Place one hand on the child’s breastbone as
indicated here. Make sure that you do not apply
pressure over the child’s ribs, the lower tip of the
breastbone or the upper abdomen.

Hand position Breastbone
Ribs
Lower tip of
breastbone

Upper
abdomen

7 Lean over the child, with your arm straight, 8 Return to the child’s head, open the airway
and then press down vertically on the and give TWO further rescue breaths.

breastbone with the heel of your hand. Depress

the chest by at least one-third of its depth. Release

the pressure without removing your hand from

the chest. Allow the chest to come back up

completely (recoil) before you give the next

compression. Compress the chest 30 times, at

a rate of 100–120 compressions per minute. The

time taken for compression and release should

be about the same.

9 If you are on your own, alternate 30 chest
compressions with TWO rescue breaths (30:2)

for one minute, then stop to call 999/112 for

emergency help. Continue CPR until: emergency

help arrives and takes over; the child shows signs

of becoming responsive – such as coughing,

opening her eyes, speaking, or moving purposefully

– and starts to breathe normally; or you become

too exhausted to continue. » 77

THE UNRESPONSIVE CASUALTY

«UNRESPONSIVE CHILD ONEYEARTOPUBERTY
SPECIAL CONSIDERATIONS FOR CPR

There are circumstances when it may be more ■■If the child vomits during CPR, roll her away
difficult to deliver CPR. While it is better to give from you onto her side, ensuring that her head
a combination of rescue breaths and chest is turned towards the floor to allow vomit to
compressions, you may not have been formally drain away. Clear the mouth, then immediately
trained in CPR or you may be unwilling or roll her onto her back again and recommence
unable to give rescue breaths. In this situation CPR.
you can give chest compressions only. The
emergency services will give instructions for ■■If the child is large, or the rescuer is small, you
chest-compression-only CPR when you call. can give chest compressions using both hands,
■■If there is more than one rescuer, change over as for an adult casualty (pp.66–67). Place one
hand on the chest, cover it with your other
every 1–2 minutes, with minimal interruption hand and interlock your fingers, keeping them
to compressions. clear of the chest.

GIVING CHEST-COMPRESSION-ONLY CPR

1 Kneel beside the child, level with her chest.
Place the heel of one hand on the centre of

her chest.

2 Lean over the child with your arm straight and
depress the chest by at least one third of the

depth, and release the pressure (but do not remove

your hand).

3 Repeat compressions at a rate of 100–120
per minute until: emergency help arrives and

takes over; the child shows signs of becoming

responsive – such as coughing, opening her eyes,

speaking, or moving purposefully – and starts to

breathe normally; or you become too exhausted

to continue.

PROBLEMS WITH RESCUE BREATHING

If a child’s chest does not rise when giving
rescue breaths:
■■Recheck the head tilt and chin lift;
■■Recheck the mouth. Remove any obvious

obstructions, but do not do a finger sweep of
the mouth.
Make no more than two attempts to achieve
rescue breaths before repeating the chest
compressions.

78

UNRESPONSIVE CHILD

VARIATIONS FOR RESCUE BREATHING

There are some cases where mouth-to-mouth
rescue breaths are not appropriate and you will
need to use a mouth-to-nose technique.

Mouth-to-nose rescue breathing
If a child has been rescued from water, or injuries to
the mouth make it impossible to achieve a good seal,
you can use the mouth-to-nose method for giving
rescue breaths. With the child’s mouth closed, form a
tight seal with your lips around the nose and blow
steadily into the casualty’s nose. Then allow the
mouth to fall open to let the air escape.

FACE SHIELDS AND POCKET MASKS through which breaths are given. If you have
one of these barrier devices, avoid unnecessary
A face shield is a plastic barrier with a filter that interruptions when giving CPR to the child.
is placed over the casualty’s mouth. A pocket
mask is more substantial and has a valve

Using a face shield Using a pocket mask
Tilt the child’s head back to open the airway and lift Kneel behind the child’s head. Open the airway and
the chin. Place the plastic shield over the child’s face place the mask, broad end towards you, over the
so that the filter is over her mouth. Pinch the nose child’s mouth and nose. Deliver breaths through
and deliver breaths through the filter. the mouthpiece.

WHEN THE AMBULANCE ARRIVES

The ambulance service may initially send you are asked to help you should listen carefully
a sole responder in a fast response vehicle or and follow the instructions given (p.23).
a community first responder ahead of the
ambulance. If an AED is not already attached The ambulance personnel will make a
to the child the ambulance personnel will do decision whether to transfer the child to
that. They will also use additional drugs and hospital immediately or to continue treatment
equipment to provide advanced care (p.57). If at the scene. Any decision to stop resuscitation
can only be made by a health care professional.

79

THE UNRESPONSIVE CASUALTY

UNRESPONSIVE INFANT UNDER ONE YEAR

The following pages describe techniques that chest compressions (cardiopulmonary
may be used for the resuscitation of an resuscitation, or CPR). Work through all of them
unresponsive infant under one year. For a child in rapid succession with minimal interruption.
over the age of one year, use the child Your first priority is to ensure that the airway
resuscitation procedure (pp.72–79). is open and clear. If normal breathing resumes
at any stage, hold the infant in the recovery
Always treat the infant from the side, the position (opposite). Call 999/112 for
correct position for doing all the stages of emergency help immediately if an infant with a
resuscitation: opening the airway, checking known heart condition becomes unresponsive.
breathing and giving rescue breaths and

HOW TO CHECK THE RESPONSE

Gently tap or flick the sole of the infant’s foot
and call his name to see if he responds. Never
shake an infant.

IF THERE IS A RESPONSE

1 Use the primary survey (pp.44–45) to identify
the most serious injury and treat conditions in

order of priority.

2 Summon help if needed – take the infant with
you to make the call. Monitor and record vital

signs – breathing, pulse and level of response

(pp.52–53) – until help arrives.

IF THERE IS NO RESPONSE
Shout for help, then lay her on her back on a firm
surface and open the airway. Go to How to open
the airway (below).

HOW TO OPEN THE AIRWAY

1 Place one hand on the 3 Now check to see if the
infant’s forehead and very infant is breathing. Go

gently tilt the head back. to How to check breathing
(opposite).

2 Place one fingertip of your
other hand on the point

of the infant's chin. Gently lift the

point of the chin. Do not push on

the soft tissues under the chin

since this may block the airway.

80

UNRESPONSIVE INFANT

HOW TO CHECK BREATHING and feel for breaths on your cheek. Do this for
no more than ten seconds.
Keep the airway open and look, listen and
feel for normal breathing – look for chest
movement, listen for sounds of breathing

IF THE INFANT IS BREATHING

1 Use the primary survey (pp.44–45) to identify
the most serious injury and treat conditions in

order of priority.

2 Hold the infant in the recovery position.
Monitor and record vital signs – breathing,

pulse and level of response (pp.52–53) – regularly

until help arrives. Go to How to hold an infant in

the recovery position (below).

IF THE INFANT IS NOT BREATHING

1 Ask a helper to call 999/112 for emergency
help. If you are on your own, perform CPR for

one minute before making the call yourself. Use

your mobile device set to speaker phone to make
the call or take the infant with you to the telephone
if necessary.

2 Begin CPR with FIVE initial rescue breaths. Go
to How to give CPR (pp.82–83).

HOW TO HOLD IN AN INFANT IN THE RECOVERY POSITION

1 Cradle the infant in your arms with his head
tilted downwards. This position prevents him

from choking on his tongue or from inhaling vomit.

2 Monitor and record vital signs – breathing,
pulse and level of response (pp.52–53) – until

help arrives.

» 81

THE UNRESPONSIVE CASUALTY

« UNRESPONSIVE INFANT UNDER ONE YEAR

HOW TO GIVE CPR

WHAT TO DO

1 Place the infant on his back on a firm surface, 3 Take a breath. Place your lips around the
at about waist height in front of you, or on the infant’s mouth and nose to form an airtight

floor. Make sure that the airway is still open by seal. If this is not possible, close the infant’s mouth

keeping one hand on the infant’s forehead and one and make a seal around the nose only. Blow gently

fingertip of the other hand under the tip of his chin. and steadily into the infant’s nose for one second;

the chest should rise.

2 Pick out any visible obstructions from mouth 4 Maintaining head tilt and chin lift, take your
and nose. Do not sweep the mouth with your mouth off the infant’s mouth and see if his

finger looking for obstructions. chest falls. If the chest rises visibly as you blow and

falls fully when you lift your mouth, you have given

a breath. Each complete rescue breath should take

one second. Give FIVE rescue breaths.

CAUTION ■■ Make up to five attempts to achieve rescue breaths,
If you cannot achieve rescue breaths: then begin chest compressions
■■ Recheck the head tilt and chin lift
■■ Recheck the infant’s mouth and nose and remove If the infant vomits during CPR, roll him away from
you onto his side to allow the vomit to drain. Resume
obvious obstructions. Do not do a finger sweep CPR as soon as possible.
■■ Check that you have a firm seal around the mouth

and nose

82

UNRESPONSIVE INFANT

5 Place two fingertips of your lower hand on the HAND POSITION
centre of the infant’s chest. Press down Place your fingers on the breastbone as indicated
here. Make sure that you do not apply pressure
vertically on the infant’s breastbone and depress over the ribs, the lower tip of the infant’s
breastbone or the upper abdomen.
his chest by at least one-third of its depth. Release

the pressure without moving your fingers from the

breastbone. Allow the chest to come back up fully

(recoil) before giving the next compression. The

time taken for compression and release should be

about the same. Repeat to give 30 compressions at

a rate of 100–120 times per minute. Finger position Breastbone
Ribs

Upper Lower tip of
abdomen breastbone

6 Return to the infant’s head, open the airway CHEST-COMPRESSION-ONLY CPR
and give TWO further rescue breaths. While it is better to give a combination of rescue
breaths and chest compressions, if you have not had
formal training in CPR, or if you are unwilling or
unable to give rescue breaths, you can give chest
compressions only. The emergency services will give
instructions for chest-compression-only CPR; put
your mobile device on speaker phone so you can
deliver first aid and talk to the ambulance dispatcher.

7 If you are on your own, alternate 30 chest
compressions with TWO rescue breaths (30:2)

for one minute then stop to call 999/112 for

emergency help. Continue CPR until: emergency

help arrives and takes over; the infant shows signs

of becoming responsive – such as coughing, CAUTION
With more than one rescuer, change every 1–2
opening his eyes, speaking or moving – and starts minutes with minimal interruption to compressions.

to breathe normally; or you become too exhausted 83

to continue.

THE UNRESPONSIVE CASUALTY

HOW TO USE AN AED

CAUTION When the heart stops, a cardiac arrest has occurred. The most
common cause is an abnormal rhythm of the heart, known as
■■ Make sure that no-one is ventricular fibrillation. This abnormal rhythm can occur when
touching the casualty because the heart muscle is damaged as a result of a heart attack or when
this will interfere with the AED insufficient oxygen reaches the heart. A machine called an AED
readings and there is a risk of (automated external defibrillator) can be used on adults and
electric shock. children over the age of one year to correct the heart rhythm
by giving an electric shock. AEDs can be used safely and
■■ Do not turn off the AED or effectively without prior training. They are available in many
remove the pads at any point, public places, including shopping centres, railway stations and
even if the casualty appears to airports – the logo opposite will be visible on the outside of the
have recovered. case. The machine analyses the casualty’s heart rhythm and
visual prompts or voice prompts describe the action to take at
■■ It does not matter if the AED each stage. In most situations when an AED is called for, you will
pads are reversed. If you put have already started CPR. When the AED is brought, continue
them on the wrong way round, with CPR while the pads are being attached to the casualty.
do not try to move them; it
wastes time and the pads may
not stick to the chest properly
when they are reattached.

WHAT TO DO

1 Switch on the AED and take the pads out 2 Remove the backing paper and attach the
of the sealed pack. Remove or cut through pads to the casualty’s chest in the positions

clothing and wipe away sweat from the chest indicated. Place the first pad on the casualty’s

if necessary. upper right side, just below his collarbone.

3 Place the second pad on the
casualty’s left side, just

below his armpit (inset above).

Make sure the pad has its long

axis along the head-to-toe axis of

the casualty’s body.

4 The AED will start analysing
the heart rhythm. Ensure

that no-one is touching the

casualty. Follow the voice and/or

visual prompts given by the

machine (opposite).

84

HOW TO USE AN AED

SEQUENCE OF AED INSTRUCTIONS

The AED will start to give you a series of visual prompts. Do not stop chest compressions while
and verbal prompts as soon as it is switched on. the pads are applied. You should follow the
There are several different AED models prompts given by the machine that you have
available, each of which has different voice until advanced care arrives.

■■ Switch on the AED.
■■ Attach pads to casualty’s chest.

AED gets ready to analyse the casualty’s heart rhythm. It may state
“Stand clear, analysing now” or “Analysing”. Make sure that no-one is
touching the casualty while it is analysing.

Is a shock advised?

YES NO

AED advises that a shock is needed; the AED advises that no shock is needed.
machine charges up.

AED instructs you to deliver the shock. AED instructs you to continue CPR for two
minutes before it re-analyses heart rhythm.
■■ Make sure everyone is clear of the casualty. The AED re-analyses heart rhythm.
■■ Depending on the type of AED, it will either

deliver the shock automatically or instruct you
to push the shock button. The casualty may
appear to “jump” with each shock; this is
quite normal.

AED instructs you to continue CPR for two European AED symbol
minutes before it re-analyses. All AED cabinets feature
a form of this symbol on
The AED re-analyses heart rhythm. the front. The European
■■ If the casualty shows signs of becoming standard one is green,
as here, but some
responsive, such as coughing, opening his companies use other
eyes, speaking or moving purposefully and colours.
starts to breathe normally, place him in the
recovery position (pp.64–65). Leave the AED » 85
attached to the casualty.

« HOW TO USE AN AEDTHE UNRESPONSIVE CASUALTY

CONSIDERATIONS WHEN USING AN AED

CAUTION The use of an AED is occasionally complicated by underlying
Never use an AED on an infant medical conditions, external factors, clothing or the cause of
under one year. the cardiac arrest. Safety of all concerned should always be
your first consideration.

CLOTHING AND JEWELLERY make rescue breaths and chest compressions
more difficult to perform, however, it will not
Any clothing or jewellery that could interfere affect the use of the AED.
with pads should be removed or cut away.
Normal amounts of chest hair are not a MEDICAL CONDITIONS
problem, but if hair prevents good contact
between the skin and the pads, it should be Some casualties with heart conditions have a
shaved off. Ensure any metal is removed from pacemaker or an implantable cardioverter
the area where the pads will be attached. defibrillator (ICD). This should not stop you
Remove clothing containing metal, such as an using an AED. However, if you can see or feel a
underwired bra. device under the chest skin, do not place the
pad directly over it. If a casualty has a patch
EXTERNAL FACTORS such as a glyceryl trinitrate (GTN) patch on the
chest, remove it before you apply the AED.
Water or excessive sweat on the chest can
reduce the effectiveness of the shock so the PREGNANT CASUALTIES
chest should be dry. If a casualty is rescued
from water (p.36), dry the chest before applying There are no contra-indications to using an
the AED pads. AED during pregnancy; however, the increased
breast size may present some problems.
If the casualty is unresponsive following an Therefore, to place the AED pads correctly, you
electric shock, start CPR immediately the may need to move one or both breasts. This
contact with electricity is broken. The electric must be carried out with respect and dignity.
current may cause muscle paralysis, which can

86

HOW TO USE AED

POSITIONING AED PADS ON CHILDREN CAUTION
Never use an AED on an infant
Standard adult AEDs can be used on children over the age of under one year.
eight years. For children between the ages of one and eight, use a
paediatric AED or a standard machine and paediatric pads. If
neither is available, then a standard AED and pads can be used.

Positioning paediatric AED pads
Place one pad in the centre of the child’s back. Then
place the second pad over the centre of the child’s
chest. Make sure both pads are vertical. Connect the
pads to the AED and proceed as described on p.85.

Using AED pads on a larger child
Place the pads on the child’s chest as for an adult –
one on the child’s upper right side, just below his
collarbone, and the second pad on the child’s left side,
just below the armpit. Make sure the pad has its long
axis along the head-to-toe axis of the child’s body.

HANDING OVER TO THE EMERGENCY SERVICES

When the emergency services arrive continue If the casualty recovers at any point, leave the
to resuscitate the child until they take over from AED pads attached to his chest. Ensure that
you. They need to know: any used materials from the AED cabinet are
■■Casualty’s present status; for example, disposed of as clinical waste (p.238). Inform
the relevant person what has been taken out
unresponsive and not breathing of the cabinet as it will need to be replaced.
■■Number of shocks you have delivered
■■When the casualty collapsed and the length

of time he has been unresponsive
■■Any relevant history, if known

87

Oxygen is essential to life. Every time
we breathe in, air containing oxygen
enters the lungs. This oxygen is then
transferred to the blood, to be transported
around the body. Breathing and the
exchange of oxygen and carbon dioxide
(a waste product from body tissues) are
described as respiration. The structures
within the body that enable us to breathe –
the air passages and the lungs – together
make up the respiratory system, and work
with the heart and circulatory system.

Respiration can be impaired in several
different ways. The airways may be blocked
causing choking or suffocation, the
exchange of oxygen and carbon dioxide in
the lungs may be affected by the inhalation
of smoke or fumes, lung function may be
impaired by chest injury, or the breathing
mechanism may be affected by conditions
such as asthma. Anxiety can also cause
breathing difficulties. Problems with
respiration can be life-threatening and
need urgent first aid.

AIMS AND OBJECTIVES

■■ To assess the casualty’s condition

■■ To identify and remove the cause of the problem and
provide fresh air

■■ To comfort and reassure the casualty

■■ To maintain an open airway, check breathing and be
prepared to resuscitate if necessary

■■ To obtain medical help if necessary. Call 999/112
for emergency help if you suspect a serious illness
or injury

RESPIRATORY
PROBLEMS

RESPIRATORY PROBLEMS

THE RESPIRATORY SYSTEM

This system comprises the mouth, nose, When we breathe, air is drawn through the nose
windpipe (trachea), lungs and pulmonary and mouth into the airway and the lungs. In the
blood vessels (the blood vessels of the lungs). lungs, oxygen is taken from air sacs (alveoli) into
Respiration involves the process of breathing the pulmonary capillaries. At the same time,
and the exchange of gases (oxygen and carbon carbon dioxide is released from the capillaries
dioxide) both in the lungs and in cells into the alveoli. The carbon dioxide is then
throughout the body. expelled as we breathe out. An average man’s
lungs can hold approximately 6 litres (10 pints)
We breathe in air to take oxygen into the of air; a woman’s lungs can hold about 4 litres
lungs, and we breathe out to expel the waste (7 pints) of air.
gas, carbon dioxide, a by-product of respiration.

Structure of the Epiglottis
respiratory system
The lungs form the central Larynx
part of the respiratory system.
Together with the circulatory Windpipe (trachea)
system, they perform the vital extends from the larynx to
function of gas exchange in order to two main bronchi
distribute oxygen around the body
and remove carbon dioxide. Windpipe divides into
two main bronchi (sing.
Ribs surround bronchus), one to each
and protect the lung, further subdivide
chest cavity into smaller bronchi,
Intercostal muscles then bronchioles
span spaces
between ribs Bronchioles are small
air passages that
Lungs are two branch from bronchi
spongy organs that and eventually open
occupy a large part into air sacs (alveoli)
of the chest cavity within the lungs

Bronchiole

Alveolus

Diaphragm is a sheet of muscle Pleural membrane, which Pulmonary
that separates chest and has two layers separated capillary
abdominal cavities by a lubricating fluid,
surrounds and protects Gas exchange in air sacs
90 each of the lungs A network of tiny blood vessels
(capillaries) surrounds each air sac
(alveolus). The thin walls of both
structures allow oxygen to diffuse into
the blood and carbon dioxide to leave it.

THE RESPIRATORY SYSTEM

HOW BREATHING WORKS in the lungs is lower than outside, air is drawn
in; when pressure is higher, air is expelled. The
The breathing process consists of the actions pressure within the lungs is altered by the
of breathing in (inspiration) and breathing out movements of the two main sets of muscles
(expiration), followed by a pause. Pressure involved in breathing: the intercostal muscles
differences between the lungs and the air and the diaphragm.
outside the body determine whether air is
drawn in or expelled. When the air pressure

Intercostal muscles Intercostal muscles
between ribs contract between ribs relax

Lung Lung
inflates deflates

Diaphragm contracts and Ribs rise and Diaphragm returns to Ribs move down
moves down swing outwards domed position and inwards

Breathing in Breathing out
The intercostal muscles (the muscles between the ribs) The intercostal muscles relax, and the ribcage returns to
and the diaphragm contract, causing the ribs to move its resting position, while the diaphragm relaxes and
up and out, the chest cavity to expand, and the lungs to resumes its domed shape. As a result, the chest cavity
expand to fill the space. As a result, the pressure inside becomes smaller, and pressure inside the lungs
the lungs is reduced, and air is drawn into the lungs. increases. Air flows out of the lungs to be exhaled.

HOW BREATHING IS CONTROLLED

Breathing is regulated by a group of nerve cells muscles and the diaphragm to contract, and a
in the brain called the respiratory centre. This breath occurs. Our breathing rate can be altered
centre responds to changes in the level of consciously under normal conditions or in
carbon dioxide in the blood. When the carbon response to abnormal levels of carbon dioxide,
dioxide level in the body rises, the respiratory low levels of oxygen, or with stress, exercise,
centre reacts by stimulating the intercostal injury or illness.

91

RESPIRATORY PROBLEMS

HYPOXIA

RECOGNITION This condition arises when there is insufficient oxygen in the
body tissues. There are a number of causes of hypoxia, ranging
In moderate and severe hypoxia, from suffocation, choking or poisoning to impaired lung or brain
there will be: function. The condition is accompanied by a variety of
■■ Rapid breathing symptoms, depending on the degree of hypoxia. If not treated
■■ Breathing that is distressed or quickly, hypoxia is potentially fatal because a sufficient level of
oxygen is vital for the normal function of all the body organs and
gasping tissues, especially the brain.
■■ Difficulty speaking
■■ Grey-blue skin (cyanosis). At first, In a healthy person, the amount of oxygen in the air is more
than adequate for the body tissues to function normally.
this is more obvious in the However, in an injured or ill person, a reduction in oxygen
extremities, such as lips, nailbeds reaching the tissues results in deterioration of body function.
and earlobes, but as the hypoxia
worsens cyanosis affects the rest Mild hypoxia reduces a casualty’s ability to think clearly, but
of the body the body normally responds to this by increasing the rate and
■■ Anxiety depth of breathing (p.91). However, if the oxygen supply to the
■■ Restlessness brain cells is cut off for as little as three to four minutes, the
■■ Headache brain cells will begin to die. All the conditions covered in this
■■ Nausea and possibly vomiting chapter can result in hypoxia.
■■ Cessation of breathing if the hypoxia
is not quickly reversed

INJURIES OR CONDITIONS CAUSING LOW BLOOD OXYGEN (HYPOXIA)

INJURY OR CONDITION CAUSES

Insufficient oxygen in inspired air ■■Suffocation by smoke or gas ■ Changes in atmospheric pressure, for
example, at high altitude or in a depressurised aircraft

Airway obstruction ■ Blocking or swelling of the airway ■ Hanging or strangulation
■ Something covering the mouth or nose ■ Asthma ■ Choking
■ Anaphylaxis

Conditions affecting the chest wall ■ Crushing, for example, by a fall of earth or sand or pressure from a crowd
■ Chest wall injury with multiple rib fractures or constricting burns

Impaired lung function ■ Lung injury ■ Collapsed lung ■ Lung infections, such as pneumonia

Damage to the brain or nerves ■ A head injury or stroke that damages the breathing centre in the brain
that control respiration ■ Some forms of poisioning ■ Paralysis of nerves controlling the
muscles of breathing, as in spinal cord injury

Impaired oxygen uptake by ■■Carbon monoxide or cyanide poisioning ■ Shock
the tissues

SEE ALSO Anaphylactic shock p.223 | Asthma p.102 | Burns to the airway p.177 | Croup p.103 | Drowning p.100 |

92 Hanging and strangulation p.97 | Inhalation of fumes pp.98–99 | Penetrating chest wound pp.104–05 | Stroke pp.212–13

HYPOXIA | AIRWAY OBSTRCTION

AIRWAY OBSTRUCTION

The airway may be obstructed externally or internally, for CAUTION
example, by an object that is stuck at the back of the throat ■■ If the casualty is unresponsive,
(pp.94–96). The main causes of obstruction are:
■■Inhalation of an object, such as food open the airway and check
■■Blockage by the tongue, blood or vomit while a casualty is breathing (The unresponsive
casualty, pp.54–87).
unresponsive (p.59)
■■Internal swelling of the throat occurring with burns, scalds, RECOGNITION
■■ Features of hypoxia (opposite), such
stings or anaphylaxis
■■Injuries to the face or jaw as grey-blue tinge to the lips,
■■An asthma attack in which the small airways in the lungs earlobes and nailbeds (cyanosis)
■■ Difficulty speaking and breathing
constrict (p.102) ■■ Noisy breathing
■■External pressure on the neck, as in hanging or strangulation. ■■ Red, puffy face
■■Peanuts, which can swell up when in contact with body fluids. ■■ Signs of distress from the casualty,
who may point to the throat or grasp
These pose a particular danger in young children because they the neck
can completely block the airway ■■ Flaring of the nostrils
Airway obstruction requires prompt action; be prepared to give ■■ A persistent cough
chest compressions and rescue breaths if the casualty stops
breathing (The unresponsive casualty, pp.54–87). YOUR AIMS
The information on this page is appropriate for all causes of ■■ To remove the obstruction
airway obstruction, but if you need detailed instructions for ■■ To restore normal breathing
specific situations, refer to the relevant pages given below. ■■ To arrange removal to hospital

WHAT TO DO

1 Remove the obstruction
if it is external or visible in

the mouth.

2 If the casualty is responsive
and breathing normally,

reassure him, but keep him

under observation.

3 Even if the casualty appears
to have made a complete

recovery, call 999/112 for

emergency help. Monitor and

record his vital signs – breathing,

pulse and level of response

(pp.52–53) – until help arrives.

SEE ALSO Asthma p.102 | Burns to the airway p.177 | Choking adult p.94 | Choking child p.95 | 93
Choking infant p.96 | Drowning p.100 | Hanging and strangulation p.97 | Inhalation of fumes pp.98–99

RESPIRATORY PROBLEMS

CHOKING ADULT

CAUTION A foreign object that is stuck in the throat may block it and
■■ If at any stage the casualty cause muscular spasm. If blockage of the airway is mild, the
casualty should be able to clear it; if it is severe, she will be
becomes unresponsive, open unable to speak, cough or breathe, and will eventually become
the airway and check breathing unresponsive. If she is unresponsive the throat muscles may
(p.63). If she is not breathing, relax and the airway may open enough to do rescue breathing. Be
begin CPR (pp.66–69) to try to prepared to begin rescue breaths and chest compressions.
relieve the obstruction.
WHAT TO DO
RECOGNITION
Ask the casualty: “Are you 1 If the casualty is breathing, 3 If back blows fail to clear the
choking?” encourage her to continue obstruction, try abdominal
Mild obstruction:
■■ Casualty able to speak, cough and coughing. Remove any obvious thrusts. Stand behind the

breathe obstruction from the mouth. casualty and put both arms
Severe obstruction:
■■ Casualty unable to speak, cough or around the upper part of her

breathe, and eventually becomes abdomen. Make sure that she is
unresponsive
still bending well forwards.
YOUR AIMS
■■ To remove the obstruction Clench your fist and place it
■■ To arrange urgent removal to
between the navel and the
hospital if necessary
bottom of her breastbone. Grasp

your fist firmly with your other

hand. Pull sharply inwards and

upwards up to five times.

2 If the casualty cannot speak
or stops coughing or

breathing, carry out back blows.

Support her upper body with one

hand, and help her to lean well

forward. Give up to five sharp

blows between her shoulder

blades with the heel of your

hand. Stop if the obstruction

clears. Check her mouth.

4 Check her mouth. If
the obstruction has not

cleared, call 999/112 for

emergency help.

5 Repeat steps 2 and 3 –
rechecking the mouth

after each step – until help

arrives or the casualty

becomes unresponsive (see

CAUTION, above, left).

94 SEE ALSO Unresponsive adult pp.62–71

CHOKING ADULT | CHOKING CHILD

CHOKING CHILD ONE YEAR TO PUBERTY

Young children especially are prone to choking. A child may CAUTION
choke on food, or may put small objects into her mouth and ■■ If at any stage the child
cause a blockage of the airway.
becomes unresponsive, open
If a child is choking, you need to act quickly. If she becomes the airway and check breathing
unresponsive, the throat muscles may relax and the airway (p.73). If she is not breathing,
may open enough to do rescue breathing. Be prepared to begin CPR to try to relieve the
begin rescue breaths and chest compressions. obstruction (pp.76–79).

WHAT TO DO RECOGNITION

1 If the child is breathing, 3 If the back blows fail, try Ask the child: “Are you choking?”
encourage her to cough; abdominal thrusts. Put your Mild obstruction:
■■ Child able to speak, cough and
this may clear the obstruction. arms around the child’s upper
breathe
Remove any obvious obstruction abdomen. Make sure that she is Severe obstruction:
■■ Child unable to speak, cough or
from her mouth. bending well forwards. Place
breathe, and eventually becomes
your fist between the navel and unresponsive

the bottom of her breastbone, YOUR AIMS

and grasp it with your other ■■ To remove the obstruction
■■ To arrange urgent removal
hand. Pull sharply inwards and
to hospital if necessary
upwards up to five times. Stop

if the obstruction clears.

2 If the child cannot speak, or
stops coughing or breathing,

carry out back blows. Bend her

well forward and give up to five

blows between her shoulder

blades using the heel of your

hand. Check her mouth, but do

not sweep the mouth with

your finger.

4 Check the mouth. If
the obstruction has not

cleared, call 999/112 for

emergency help.

5 Repeat steps 2 and 3 –
rechecking the mouth after

each step – until help arrives or

the child becomes unresponsive

(see CAUTION, above, right).

SEE ALSO Unresponsive child pp.72–79 95

RESPIRATORY PROBLEMS

CHOKING INFANT UNDER ONE YEAR

CAUTION An infant is more likely to choke on food or small objects than
■■ If at any stage the infant an adult. The infant will rapidly become distressed, and you need
to act quickly to clear any obstruction. If the infant becomes
becomes unresponsive, open unresponsive, the throat muscles may relax and the airway may
the airway and check breathing open enough to do rescue breathing. Be prepared to begin
(pp.80–81). If the infant is not rescue breaths and chest compressions.
breathing, begin CPR (pp.82–83)
to try to relieve the obstruction. WHAT TO DO

RECOGNITION 1 If the infant is unable to cry, 3 If back blows fail to clear
Mild obstruction: cough or breathe, lay her the obstruction, try chest
■■ Infant able to cough, but has
face down along your forearm thrusts. These are similar to
difficulty crying or making any
other noise and thigh and support her head. chest compressions, but sharper
Severe obstruction:
■■ Unable to make any noise or Give up to five back blows in nature and delivered at a
breathe, and eventually becomes
unresponsive between the shoulder blades, slower rate. Lay the infant face

YOUR AIMS with the heel of your hand. up on your leg, place two fingers
■■ To remove the obstruction
■■ To arrange urgent removal on the lower part of the

to hospital if necessary breastbone one finger’s breadth

below the nipple line and push

downwards. Give up to five

chest thrusts.

2 Turn the infant over so
that she is face up along

your other leg and check her

mouth. Remove any obvious

obstructions with your Check the mouth. If the
obstruction still has not
fingertips. Do not sweep the 4

mouth with your finger as this cleared, call 999/112 for

may push the object further emergency help; take the infant

down the throat. with you if necessary.

5 Repeat steps 1 to 3 –
rechecking the mouth after

each step – until help arrives or

the infant becomes unresponsive

(see CAUTION, above left).

96 SEE ALSO Unresponsive infant pp.80–83

CHOKING INFANT | HANGING AND STRANGULATION

HANGING AND STRANGULATION

If pressure is exerted on the outside of the neck, the airway is CAUTION
squeezed and the flow of air to the lungs is cut off. The main ■■ Do not move the casualty
causes of such pressure are:
■■Hanging – suspension of the body by a noose around unnecessarily, in case of spinal
injury.
the neck. ■■ Do not destroy or interfere with
■■Strangulation – constriction or squeezing around the neck any material that has been
constricting the neck, such as
or throat. knotted rope as the police may
Sometimes, hanging or strangulation may occur accidentally – need it for evidence.
for example, by ties or clothing becoming caught in machinery. ■■ If the casualty is unresponsive,
Hanging may cause a broken neck; for this reason, a casualty in open the airway and check
this situation must be handled extremely carefully. breathing (The unresponsive
casualty, pp.54–87).
WHAT TO DO
RECOGNITION
1 Quickly remove any ■■ A constricting article around
constriction from around
the neck
the casualty’s neck. ■■ Marks around the casualty’s neck
■■ Rapid, difficult breathing; impaired
2 If the casualty is hanging,
support the body while consciousness; grey-blue skin
(cyanosis)
you relieve the constriction. Be ■■ Congestion of the face, with
prominent veins and, possibly, tiny
aware that the body will be very red spots on the face or on the
whites of the eyes
heavy if he is unresponsive.
YOUR AIMS
3 If the casualty is responsive, ■■ To restore adequate breathing
help him to lie down while ■■ To arrange urgent removal

supporting his head and neck. to hospital

4 Call 999/112 for emergency
help, even if he appears to

recover fully. Monitor and record

his vital signs – breathing, pulse

and level of response (pp.52–53)

– until help arrives.

SEE ALSO Spinal injury pp.157–59 | The unresponsive casualty pp.54–87 97

RESPIRATORY PROBLEMS

INHALATION OF FUMES

The inhalation of smoke, gases (such as carbon Casualties who have suffered from fume
monoxide) or toxic vapours can be lethal. A inhalation should also be examined for other
casualty who has inhaled fumes is likely to have injuries due to the fire, such as external burns.
low levels of oxygen in his body tissues
(Hypoxia, p.92) and therefore needs urgent INHALATION OF CARBON
medical attention. MONOXIDE

Do not attempt to carry out a rescue if it is Carbon monoxide is a poisonous gas, but it is
likely to put your own life at risk; fumes that hard to detect as it has no taste or smell. The
have built up in a confined space will quickly gas acts directly on red blood cells, preventing
overcome anyone who is not wearing them from carrying oxygen to the body tissues.
protective equipment. If carbon monoxide is inhaled in large
quantities – for example, from smoke or
SMOKE INHALATION vehicle exhaust fumes in a confined space –
it can very quickly prove fatal. However,
Any person who has been enclosed in a lengthy exposure to even a small amount of
confined space during a fire should be assumed carbon monoxide – for example, due to a
to have inhaled smoke. Smoke from burning leakage of fumes from a defective heater or
plastics, foam padding and synthetic wall flue – may also prove fatal.
coverings is likely to contain poisonous fumes.

EFFECTS OF FUME INHALATION

FUMES POSSIBLE SOURCE EFFECTS
Prolonged exposure to low levels:
Carbon ■ Exhaust fumes of motor vehicles ■ Smoke ■ Headache ■ Confusion ■ Aggression ■ Nausea
monoxide from most fires ■ Back-draughts from blocked and vomiting ■ Diarrhoea
chimney flues ■ Emissions from defective gas Brief exposure to high levels:
or paraffin heaters and poorly maintained ■ Grey-blue skin coloration ■ Rapid, difficult breathing
boilers ■ Disposable or portable barbeques ■ Impaired level of response, leading to
used in a confined space unresponsiveness
■ Rapid, noisy and difficult breathing ■ Coughing and
Smoke ■ Fires: smoke is a bigger killer than fire itself. wheezing ■ Burning in the nose or mouth ■ Soot
Smoke is low in oxygen (which is used up by the around the mouth and nose ■ Unresponsiveness
burning of the fire) and may contain toxic fumes
from burning materials.

Carbon ■ Tends to accumulate and become dangerously ■ Breathlessnes ■ Headache ■ Confusion
dioxide concentrated in deep enclosed spaces, such as ■ Unresponsiveness
coal pits, wells and underground tanks

Solvents ■ Glues ■ Cleaning fluids ■ Lighter fuels ■ Headache and vomiting ■ Impaired level of
and fuels ■ Camping gas and propane-fuelled stoves response ■ Airway obstruction from using a plastic
(Solvent abusers may use a plastic bag to bag or from choking on vomit may result in death ■
concentrate the vapour, especially with glues) Solvent abuse is a potential cause of cardiac arrest

98